Infection Control Today: Environmental Services

ENVIRONMENTAL SURFACE CLEANINGFirst Defense Against Infectious Agents

Infectious organisms lurking on healthcare surfaces contribute
to nosocomial infection. Proper management and eradication methods are
imperative in striving for a clean environment.

Nosocomial infection its
deadly, its prevalent, and the organisms that cause it are found virtually
everywhere. Approximately 5.7 percent (2,000,000) of all patients admitted to
U.S. hospitals acquire nosocomial infections, of which 3.8 percent prove
fatal.1 That calculates to 70,000 people dying every year from such
infections.

Nosocomial infection can be caused by a vast array of
organisms. Those most prevalent include chemically resistant organisms
such as Clostridium difficile (C-difficile),
multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus
aureus (MRSA) and vancomycin-resistant Enterococcus
(VRE).2 Another group of great concern are extended-spectrum beta-lactamases or
ESBL.

Prions and bacterial spores also are extremely resistant and
difficult to kill, and it has been determined that intermediate resistance to
disinfection is demonstrated by mycobacterium and non-enveloped viruses. Those
easier to eradicate from the environment include fungi, vegetative bacteria such
as Pseudomonas, and enveloped viruses.

It is known that dry conditions favor the persistence of
gram-positive cocci in dust and on surfaces, while moist, soiled environments
favor the growth and persistence of gram-negative bacilli.

According to National Nosocomial Infection Surveillance (NNIS)
statistics for infections acquired among ICU patients in the United States in
1999, 52.3 percent of infections resulting from Staphylococcus
aureus were identified as MRSA infections, and 25.2
percent of enterococcal infections were attributed to VRE. These figures reflect
a 37 percent and a 43 percent increase, respectively, since 1994 to 1998.

Environmental surfaces of nearly any kind are a possible
breeding pool for such infectious organisms. For example, environmental surfaces
have been shown to be a potential reservoir for nosocomial transmission of VRE.3

VRE is capable of prolonged survival on hands, gloves, and
environmental surfaces. In fact, in a study conducted at Northwestern University
Medical School, E. faecalis was recoverable from countertops for five days, and
E. faecium persisted for seven days. For bedrails, both enterococcal species
survived for 24 hours without significant reduction in colony counts. The
researchers also found that bacteria persisted for 60 minutes on a telephone
hand piece and for 30 minutes on the diaphragmatic surface of a stethoscope.

C. difficile is an anaerobic, gram-positive bacterium.4
Normally fastidious in its vegetative state, it is capable of sporulating when
environmental conditions no longer support its continued growth. The capacity to form spores enables this organism to persist
in the environment (e.g., in soil and on dry surfaces) for extended periods of
time. Environmental contamination by this microorganism is well known,
especially in places where fecal contamination may occur. The environment
(especially housekeeping surfaces) rarely serves as a direct source of infection
for patients, however, direct exposure to contaminated patient-care items (e.g.,
rectal thermometers) and high-touch surfaces in patients bathrooms (e.g.,
light switches) have been implicated as sources of infection.

Acinetobacter baumannii (A.
baumannii) is ubiquitous and has become one of the many recognized
healthcare-associated pathogens in hospitals.5 During a two-month period, an
outbreak of pan-drug resistant A. baumannii colonization and infection affecting
seven patients occurred in a Taiwan surgical intensive care unit. Extensive
environmental contamination was identified, including sites such as bed rails,
bedside tables, the surfaces of ventilators and infusion pumps, water for
nasogastric feeding and ventilator rinsing and sinks.

In 2002, an outbreak of multidrug-resistant A. baumannii,
involving 21 patients, occurred in a trauma intensive care unit at the Hamad
Medical Corporation in Qatar.6 The A. baumannii strain was isolated from the
environment, equipment, and hands of healthcare workers (HCWs). The researchers
concluded the technique of open suctioning may have resulted in aerosilization
and contamination of the immediate patient environment.

ESBL is fast becoming a serious concern in healthcare. The
first beta-lactamase was identified in an isolate of Escherichia
coli in 1940.7 ESBL represents an impressive example of the ability of
gramnegative bacteria to develop new antibiotic resistance mechanisms in the face of the introduction of new antimicrobial agents.8

One French study found five ESBL-producing enterobacteria
(ESBLE) responsible for urinary tract infections (UTIs) found among 1,584
strains collected from community patients.9 The aim of this study was to reveal
the route of emergence. The researchers ultimately found the same ESBLE and/or
an identical or similar ESBL-encoding plasmid in a hospital ward and in a clinic where the patients had
previously resided.

Studies have shown that in rooms of patients who were
colonized or infected, 70 percent of environmental surfaces were contaminated
with potentially harmful microorganisms, says David Parks, general manager of
global infection control products with Kimberly-Clark Health Care. Once these surfaces become contaminated, without proper
disinfection they can remain contaminated for extensive periods of time.

The number and types of microorganisms present on
environmental surfaces are influenced by the following factors:4

Number of people in the environment

Amount of activity

Amount of moisture

Presence of material capable of supporting microbial
growth

Rate at which organisms suspended in the air are removed, and

Type of surface and orientation (i.e., horizontal or vertical).

Gordon Buntrock, director of product development,
environmental services for Aramark Healthcare Management Services, points out,
Healthcare delivery and the environment are interdependent; one cannot be
achieved without the other. There are a number of organizations such as the
Centers for Disease Control and Prevention (CDC) and the Association of
PeriOperative Registered Nurses (AORN) that provide guidelines that should be
looked at for cleaning within the acute care environment. Documents such as Guidelines
for Environmental Infection Control in Health Care Facilities from the CDC
and Standards, Recommended Practices, and Guidelines from AORN are
critical readings associated specifically to healthcare cleaning and cleaning of
surgical areas.

It is important to note that although microbiologically
contaminated surfaces can serve as reservoirs of potential pathogens, these
surfaces generally are not directly associated with transmission of infections
to either staff or patients.4 Surfaces contribute to cross-transmission by
acquisition of transient hand carriage due to contact with contaminated surfaces
or medical equipment.10 So the transfer of microorganisms from environmental
surfaces to patients is largely via hand contact with the surface.4

Hand hygiene may be the single most important factor in
ensuring a clean environment and reducing the spread of all types of microbial
contamination, such as MRSA and VRE, affirms Chuck Allgood, PhD, technical
support leader with DuPont Safety and Protection.

Rose Hamann, CHESP, director of environmental services and
security, and Carleen Orton, an infection control nurse, both of Quincy, Ill.-
based Blessing Hospital, agree, warning, First and foremost for any
healthcare worker is the diligent washing or alcohol disinfection of their hands
stop the germs from spreading, they say.

Orton says the pathogens their facility educates personnel on
specifically are VRE, MRSA, and C. difficile. Also, hepatitis B and C, she says. We ensure the staff realizes reactivation may
occur if the blood becomes moistened at a later date.

Our city had an outbreak of VRE coming from a long-term
care nursing facility, Hamann continues. We did a huge campaign for
handwashing and awareness of disinfecting all areas where patients hands
would touch. Our infection control nurse did a swab of the chair scales on one
of our nursing units and found VRE. We did educational reminders for staff to
disinfect all patient equipment, and environmental services was in-serviced on
the areas needing disinfection and daily attention in patient care areas. The
surfaces such as hand rails, door knobs, and overbed tables were a few of the
highlighted areas.

When attempting to ensure a clean healthcare environment, HCWs
must look beyond environmental surface contamination and also focus on portable
equipment and protective apparel contamination, as they too play a key role in
the spread of infection, according to Parks. During their daily routine, healthcare workers frequently
carry thermometers, blood pressure cuffs, and stethoscopes from one patients
room to another patients room. Each of these pieces of equipment can become
contaminated by one patient and lead to the cross-infection of another patient.

Protective apparel can be another source of contamination,
he continues. One study found that when caring for patients with MRSA and
VRE, 69 percent of healthcare workers lab coats were contaminated, and 27
percent of their hands were contaminated after touching their lab coats. Gloves
have also been shown to be contaminated with MRSA 42 percent of the time after
touching environmental surfaces without having touched the patient.

So during an average day in a healthcare environment, the
surfaces in the patients room, the equipment used to treat patients, and even
the apparel worn to protect the healthcare workers can all be vehicles in the
spread of infection. Therefore, proper disinfection of surfaces and portable
equipment, and the use of disposable protective apparel as well as adherence
to proper hand hygiene are all necessary to minimize the risk of
cross-infection.

According to the CDC, there are three levels of disinfection
for the treatment of devices and surfaces that do not require sterility for safe use. They are high-level, intermediate-level, and
low-level.4

The process of high-level inactivates all vegetative bacteria,
mycobacteria, viruses, fungi, and some bacterial spores. High-level disinfection
is accomplished with powerful, sporicidal chemicals (e.g., glutaraldehyde,
peracetic acid, and hydrogen peroxide) that are not appropriate for use on
housekeeping surfaces.

Intermediate-level disinfection does not necessarily kill
bacterial spores, but it does inactivate Mycobacterium
tuberculosis var. M.bovis, which is substantially more resistant to chemical
germicides than ordinary vegetative bacteria, fungi, and medium to small viruses
(with or without lipid envelopes). Chemical germicides with sufficient potency
to achieve intermediate-level disinfection include chlorinecontaining compounds
(e.g., sodium hypochlorite), alcohols, some phenolics, and some iodophors.

Buntrock adds that in 1991, CDC proposed an additional
category designated environmental surfaces to Spauldings original
classification to represent surfaces that generally do not come into direct
contact with patients during care. Environmental surfaces carry the least
risk of disease transmission and can be safely decontaminated using less
rigorous methods than those used on medical instruments and devices, he
shares. Environmental surfaces can be further divided into medical equipment
surfaces (e.g., knobs or handles on hemodialysis machines, X-ray machines,
instrument carts, and dental units) and housekeeping surfaces (e.g., floors,
walls, tabletops).

At a minimum, any hard surface disinfectant should be
EPA-registered and proven effective against the organisms of concern, and be
safe to both those who apply them as well as others who may be exposed, Allgood says. The specific area of a healthcare facility
(operating rooms, labs, patient rooms, emergency rooms, waiting rooms, neonatal
units, etc.), will determine exactly what level of cleaning and disinfecting is
needed. In virtually all cases, a broad spectrum disinfectant is preferred.

In specific circumstances, disinfectants should be effective
against expected organisms, for example emergency rooms and labs should use
products that meet the OSHA bloodborne pathogen standard, Allgood points out.
Ideally, one would use products applicable in as many areas as possible.
These disinfectants have efficacy against a wide range of human pathogens
including hepatitis A, B, and C, MRSA, VRE, influenza, RSV, and norovirus.
Products that work well in the presence of soil (clean and disinfect in one step) are
preferred since some types of disinfectants such as bleach and quaternary
ammonium compounds are inactivated under heavy soil load.

Allgood adds, Understanding the shelf life, dilution
requirements, and compatibility with materials that will be contacted either
intentionally or inadvertently are also very important in choosing a
disinfectant. For instance, bottles of bleach have a recommended shelf life
of three to six months and in-use solution should be made up daily.

Targeted disinfection of environmental surfaces are
established components of hospital infection control.11 Careful cleaning of
patient rooms and medical equipment contributes substantially to the overall
control of MRSA, VISA (vancomycin intermediate resistant S. aureus), or VRE
transmission.4 Both MRSA and VRE are susceptible to several EPA-registered low-
and intermediate-level disinfectants (e.g., alcohols, sodium hypochlorite,
quaternary ammonium compounds, phenolics, and iodophors) at recommended use
dilutions for environmental surface disinfection. Additionally, both VRE and
vancomycin-sensitive enterococci are equally sensitive to inactivation by
chemical germicides, and similar observations have been made when comparing the
germicidal resistance of MRSA to that of either methicillin-sensitive Staphylococcus
aureus (MSSA) or VISA. The use of stronger solutions
of disinfectants for inactivation of VRE, MRSA, or VISA is not recommended based
on the organisms resistance to antibiotics.

This points to another consideration. Keep in mind the
repercussions of the use of certain chemicals. The toxicity and chemical
nature of certain disinfectants (fumes) may limit or preclude their use in
certain areas, i.e. products with irritating fumes may not be used in areas with
young children or respiratory patients, Allgood points out.

New research is being conducted all the time to reduce any
consequences of such cleaning materials. New disinfectants, mainly peroxygen
compounds, are showing good sporicidal properties in recent research and will
probably evolve to replace the more problematic substances such as chlorine-releasing agents.11

Compatibility of the material or surface the disinfectant or
cleaner will be used on is another key issue and should be established early on.
For instance, bleach can be very corrosive and damaging to a large number of
materials such as stainless steel that need to be disinfected. It also results
in collateral damage to fabrics, carpeting, and clothing upon incidental
contact, Allgood asserts.

Hamann says her facility alerts staff to use a bleach
solution. If we see an outbreak of C. difficile,
staff is alerted to use bleach solution in these patient rooms to lessen the
chance of cross contamination, she says.

Strategies for cleaning and disinfecting surfaces in
patient-care areas should take into account the potential for direct patient
contact, degree and frequency of hand contact, and potential contamination of
the surface with body substances or environmental sources of microorganisms (e.g., soil, dust, and water).4

The factors influencing the choice of disinfection procedure
for environmental surfaces include the nature of the item to be disinfected, the
number of microorganisms present, the innate resistance of those microorganisms
to the inactivating effects of the germicide, the amount of organic soil
present, the type and concentration of germicide used, duration and temperature
of germicide contact, and if using a proprietary product, other specific
indications and directions for use.4

Keep in mind that cleaning is the necessary first step of
any sterilization or disinfection process and is needed to render the
environmental surface safe to handle or use by removing organic matter, salts,
and visible soils all of which interfere with microbial inactivation, says Robin Morris, customer
marketing manager for healthcare with Kimberly-Clark Professional. In fact,
the physical action of scrubbing with detergents and surfactants and rinsing
with water removes large numbers of microorganisms from surfaces. Most, if not
all, housekeeping surfaces require regular cleaning with soap and water or a
detergent/disinfectant and removal of soil and dust, according to the CDC
guidelines. High-touch housekeeping surfaces in patient-care areas, such as
doorknobs, bedrails, light switches, wall areas around the toilet, and the edges
of privacy curtains, should be cleaned and/or disinfected more frequently than
surfaces with minimal hand contact. Horizontal surfaces with infrequent hand
contact, such as window sills and hard-surface flooring in routine patient-care
areas require cleaning on a regular basis, when soiling or spills occur, and
when a patient is discharged from the facility.

Orton points out that wiping down the equipment immediately
after use helps to cut down on microbial growth. In addition, as Hamann points
out, ES is not routinely responsible for equipment, but we do help others
when needed, she says. We also remind or bring to attention of the nursing
staff if we see unclean or dusty equipment. We are all in this together and need
to work as a team to help prevent cross-contamination not only do we protect
others, but also ourselves in doing this.

Perhaps the best plan of action, according to Allgood, is to
mimic the Hazard Analysis and Critical Control Point (HACCP) plan used in the
food industry to control microbes in food production facilities. Allgood advises, The healthcare industry should develop a
similar plan for monitoring and disinfecting critical locations in the hospital
environment to minimize the spread of dangerous pathogens. Because cleaning
services may not always clean thoroughly, a monitoring program should be
initiated to validate the effectiveness of cleaning and disinfection of hospital
surfaces. Common errors in dilution of concentrates or in topping off
containers of ready-to-use disinfectants with diminished activity need to be
corrected immediately and standard operating procedures must be reviewed often.

Overall, Allgood says the best plan would combine a regular
scheduled cleaning, disinfection, and monitoring program as described above
along with rapid response and containment of unexpected events, (i.e. spill of blood/body fluid, fecal accidents) in
order to prevent small incidents from developing into major outbreaks.

Any hard non-porous surface should be considered an area
needing cleaning and disinfection, he adds. The frequency of cleaning and
disinfecting depends on a number of factors including likelihood of
contamination and potential exposure risk for others. Areas and surfaces
frequently contacted by many people, especially those sick (beds, stretchers,
hand rails, rest rooms, door knobs, floors throughout the facilities, etc.)
would be the highest priority.

All areas within the hospital are not created equal in the
amount of daily cleaning and level of cleaning that has to take place, adds
Buntrock. A strategy has to be created for different areas of the hospital
and it is usually determined by a risk assessment. Usually, this is based on the
use of the area and the potential for transmission of nosocomial infection. It
is important to understand that cleaning in hospitals has to take place with
regularity, that housekeeping is focused on the cleaning of environmental
surfaces. It is also important to understand that it is important that
housekeeping focuses on the removal of microorganisms through routine mechanical
action and good detergency. The goal of daily housekeeping is to remove soil,
dust, and pathogens. It is also important to know that gravity plays a big role
in regards to areas that require the most cleaning. Airborne soils and
microorganisms settle on horizontal surfaces more than on vertical surfaces.

Of note, Buntrock points out, Between those areas and areas
that patients touch directly, an EPA-registered detergent/disinfectant should be
utilized when cleaning. When using disinfectants/detergents, it is still
critical to use good mechanical action and to use absorbent materials to remove
soil and microorganisms. If high volumes of soil are visible, it may be
necessary to pre-clean the surface with a cleaner that provides greater
detergency and then follow-up with the disinfectant.

When disinfectants are utilized in cleaning, it is important
that the disinfectant is not dried with a cloth, but allowed to air-dry,
providing the product more application time to disinfect. Low-level
disinfectants and intermediate-level disinfectants that housekeeping utilizes
for cleaning are only active as disinfectant when they are wet.